OSTEOARTHRITIS

ANTHONY C. SCIRÉ, JR · 2022 · Case ID: 22042674

DENIED

Summary

The veteran, who served in the United States Air Force from November 1979 to November 1984 during peacetime, appeals the denial of service connection for several conditions claimed as secondary to his service-connected degenerative disc disease (DDD) and intervertebral disc disease (IVDS) of the lumbar spine. These conditions include right shoulder, bilateral hip, bilateral knee, and bilateral ankle disabilities. The veteran contended that these secondary conditions were aggravated by a change in gait due to lower back pain and altered body mechanics. The Board reviewed multiple VA examination reports from November 2011, December 2013, March 2018, April 2019, and June 2021. The examiners consistently opined that the veteran's degenerative joint disease (DJD) in the shoulders, hips, knees, and ankles was multifactorial, primarily related to age, obesity, and genetic predisposition, rather than his service-connected lumbar spine condition or any specific in-service injury. While acknowledging the veteran's contentions about decreased mobility and the use of a cane, the examiners found no likely causative link between these factors and the development or aggravation of DJD in the affected joints. The Board found the VA opinions to be probative and consistent, concluding that the evidence did not establish a nexus to service, either directly or secondarily. Therefore, service connection for all claimed secondary conditions was denied.

Rationale

Multiple VA examiners opined DJD is multifactorial (age, obesity, genetics); Examiners found no likely causative link between lumbar spine condition and shoulder DJD; No history of traumatic shoulder injury in service

Service Branch

AIR FORCE

Special Benefit

NO SPECIAL BENEFIT

Docket No.

14-11 524

Full Decision Text

Citation Nr: 22042674
Decision Date: 07/27/22 Archive Date: 07/27/22

DOCKET NO. 14-11 524
DATE: July 27, 2022

ORDER

Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected degenerative disc disease (DDD) and intervertebral disc disease (IVDS) of the lumbar spine, is denied.

Entitlement to service connection for a right hip disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine, is denied.

Entitlement to service connection for a left hip disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine, is denied.

Entitlement to service connection for a right knee disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine, is denied.

Entitlement to service connection for a left knee disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine, is denied.

Entitlement to service connection for a right ankle disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine, is denied.

Entitlement to service connection for a left ankle disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine, is denied.

FINDINGS OF FACT

1. The Veteran's right shoulder disability is not related to an in-service injury, event, or disease, or is proximately due to, a result of, or aggravated by his service-connected DDD and IVDS of the lumbar spine.

2. The Veteran's right hip disability is not related to an in-service injury, event, or disease, or is proximately due to, a result of, or aggravated by his service-connected DDD and IVDS of the lumbar spine.

3. The Veteran's left hip disability is not related to an in-service injury, event, or disease, or is proximately due to, a result of, or aggravated by his service-connected DDD and IVDS of the lumbar spine.

4. The Veteran's right knee disability is not related to an in-service injury, event, or disease, or is proximately due to, a result of, or aggravated by his service-connected DDD and IVDS of the lumbar spine.

5. The Veteran's left knee disability is not related to an in-service injury, event, or disease, or is proximately due to, a result of, or aggravated by his service-connected DDD and IVDS of the lumbar spine.

6. The Veteran's right ankle disability is not related to an in-service injury, event, or disease, or is proximately due to, a result of, or aggravated by his service-connected DDD and IVDS of the lumbar spine.

7. The Veteran's left ankle disability is not related to an in-service injury, event, or disease, or is proximately due to, a result of, or aggravated by his service-connected DDD and IVDS of the lumbar spine.

CONCLUSIONS OF LAW

1. The criteria for service connection for a right shoulder disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria for service connection for a right hip disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for service connection for a left hip disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

4. The criteria for service connection for a right knee disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria for service connection for a left knee disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

6. The criteria for service connection for a right ankle disability, to include as secondary to service-connected disability, have not been met. 38
a right knee disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

6. The criteria for service connection for a right ankle disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

7. The criteria for service connection for a left ankle disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty service with the United States Air Force from November 1979 to November 1984. The Veteran served during Peacetime.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin.

The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in January 2017. A transcript of the hearing is associated with the claims file.

This case was previously before the Board in January 2018 and September 2019. In September 2019, the case was most recently remanded to provide the Veteran with new VA examinations and obtain additional VA opinions, which was accomplished in June 2021.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

A disability may be service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service connected disease or injury, or (2) aggravated by an already service connected disease or injury. 38 C.F.R. § 3.310.

The Veteran already has established his entitlement to service connection for DDD and IVDS of the lumbar spine. He contends that he has right shoulder, bilateral hip, bilateral knee, and bilateral ankle disabilities that are caused or aggravated by this lumbar spine disability, so his claims are predicated on the notion that his claimed disabilities are secondary to his lumbar spine disability. During the January 2017 Board hearing, he claimed that these disabilities were aggravated because of a change in his gait due to lower back pain. Alternatively, he claims that the disabilities additionally are a result of his service.

1. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine.

First, the Veteran has a diagnosis of right shoulder acromioclavicular joint degenerative joint disease (DJD), as noted in November 2011, December 2013 and June 2021 VA examination reports. Consequently, there is no disputing he has this claimed condition, but there also must be attribution of this condition to his military service either, as mentioned, directly or secondarily by way of a service-connected disability.

However, it is not shown that the Veteran's right shoulder DJD is related to any in-service injury, event or disease, or his service-connected lumbar spine disability caused or aggravates his right shoulder DJD.

The November 2011 VA examiner opined that it was less likely as not that the Veteran's right shoulder disability was caused by the Veteran's service or his service-connected lumbar disc disease, finding that the condition was multifactorial in etiology, was likely related to his weight and genetic composition, and was likely unrelated to his back disease or the symptomatology noted in service.

The December 2013
this condition to his military service either, as mentioned, directly or secondarily by way of a service-connected disability.

The December 2013 examiner opined that it was less likely as not that the Veteran's right shoulder DJD was causally related to the Veteran's service, concurring with the November 2011 examiner that the Veteran's right shoulder disability is multifactorial in nature, including a genetic predisposition and the Veteran's body habitus. The examiner opined that the Veteran's weight gain is likely caused by lifestyle choices and genetic predisposition. The examiner noted that there was no history of traumatic injury to his shoulder to account for the current DJD, as tendonitis is not generally thought of as causative of DJD. The examiner stated that a cane is not a commonly known risk factor for degenerative changes in the joint. As such, the examiner found that the Veteran's right shoulder was less likely than not caused by his lumbar spine disability, altered gait, or altered body mechanics or due to the weight gain caused by his lumbar spine disc disease.

In March 2018, a supplement opinion was obtained. The examiner found that the service treatment records demonstrated a right shoulder condition that was transient and reversible in nature that would not have predisposed the Veteran to right shoulder DJD. Moreover, the examiner opined, "using a cane should not cause right shoulder degenerative joint disease."

In September 2019, the Board found the VA opinions inadequate to decide the claim, remanded the claim to obtain a new examination and opinion. Specifically, the examiners failed to provide a thorough rationale with consideration of the Veteran's contention regarding decreased mobility due to his back disability on his weight, and mechanics of pressure through the shoulder and posture in use of a cane.

In June 2021, another VA examiner opined that it was less likely as not that the Veteran's right shoulder DJD is less likely than not proximately due to his service-connected lumbar spine condition. Initially, the examiner stated, all medical knowledge indicates that the primary causative factors in development of DJD are increasing age, obesity and genetic factors. Notably, it was noted DJD can develop in several joints, and in persons predisposed to DJD, it is likely that this will occur rather than DJD isolating to a single joint or region (for example lumbar spine). However, the examiner explained that DJD in one particular joint or region is not known to drive development in a different joint or region and that the physiologic and pathologic processes involved in development of DJD do not lend a likely causative link.

With regard to the Veteran's lay statements that his obesity was related to his decreased mobility and inability to remain active, the examiner noted that clearly, the Veteran's weight gain was prior to his decreased mobility and symptoms of DJD as he reached a weight of 267 pounds by March 1989 and 370 pounds by September 2001 when he was still actively driving a commercial motor vehicle (CMV). It was further noted that despite the weight gain, he exhibited the ability to successfully operate the CMV, according to his companion of over 20 years who reported "[w]hen I first met him, he was driving a truck. And he could jump into the truck. He, could unload the truck. He could travel across country. And he was very active,." in about 1995 to 1997 when he had reached a weight of over 300 pounds.

Concerning the Veteran's contention of his cane causing single arm pressure, the examiner stated "[t]ypically, canes are used to help improve mobility and stability, and are not used for support of body weight. Use of a cane is not medically caused a substantial deviation of gait or stride. To the contrary, their use is designed to correct for deviation of gait or stride. Canes are not recognized as a significant risk factor for development of DJD." Regarding the October 2011 VA physical therapy (PT) note offering a trail of using a walker to help with pain, the examiner stated the notes from this PT suggested a mild muscular issue rather than an internal joint issue.

Finally, the examiner op
.

Finally, the examiner opined that right shoulder DJD is less likely than not aggravated by his gait change or stride deviation. In support of this opinion, the examiner reasoned that DJD is a progressive chronic disease which worsens over time and with increased or heavy use and observed that the Veteran's X-ray reports indicated that his DJD in his right shoulder is moderate. The examiner concluded, given the Veteran's age and employment history and body weight, a finding of mild to moderate DJD would be the least degree expected, and it would not be unexpected to find severe degenerative changes; his right shoulder DJD has not progressed beyond its natural course, and is following a typical course of progression.

The aggregate of the VA medical examiners' opinions, which was most recently supplemented by the June 2021 VA examination report, is based on an accurate medical history (so factual predicate) and provide the required explanation or underlying reasoning or rationale, which is where most of the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Consequently, the Board afford significant probative value to the VA examiners' medical opinions. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation).

Additionally, there is no medical evidence directly linking the Veteran's right shoulder disability to his service, nor is there otherwise any competent evidence linking his right shoulder disability to his service-connected lumbar spine disability. Determining his right shoulder DJD originated during his service or is secondary to service-connected disability does not fall within the realm of capabilities of a layman to offer probative opinion concerning. See 38 C.F.R. § 3.159(a)(1), (a)(2).

In sum, the probative evidence does not link this condition to the Veteran's service either directly or secondarily by way of his service-connected DDD and IVDS of the lumbar spine. The evidence is against this claim, so service connection is denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990).

2. Entitlement to service connection for a right hip disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine.

3. Entitlement to service connection for a left hip disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine.

The Veteran has a diagnosis of right and left hip DJD, as noted in November 2011, December 2013 and June 2021 VA examination reports. Consequently, there is no disputing he has a current bilateral hip disability, but there also must be attribution of this condition to his military service either, as mentioned, directly, or secondarily by way of a service-connected disability.

However, it is not shown that the Veteran's bilateral hip DJD is related to any in-service injury, event or disease, or his service-connected lumbar spine disability caused or aggravates his bilateral hip DJD.

The November 2011 examiner opined that it was less likely as not that the Veteran's right and left hip disabilities were caused by the Veteran's service or his service-connected lumbar disc disease, finding that the condition was multifactorial in etiology, was likely related to his weight and genetic composition, and was likely unrelated to his back disease or the symptomatology noted in service.

The December 2013 examiner opined that it was less likely as not that the Veteran's right and left hip DJD was causally related to the Veteran's service, concurring with the November 2011 examiner that the Veteran's bilateral hip disability is multifactorial in nature, including a genetic predisposition and the
bilateral hip DJD.

In March 2018, a supplemental VA opinion was obtained. The examiner contended that it was less likely as not that the Veteran's hip disabilities either manifested in service or were attributable to the Veteran's lumbar spine DDD. The examiner opined that, although the Veteran was hit by a hose cart, the result was not an injury sufficient to predispose him to DJD of either hip. The examiner went on to state that obesity was multifactorial related to oral intake and calorie expenditure; therefore, the Veteran's lumbar spine DDD was less likely as not the cause of the Veteran's obesity and, as such, this was less likely than not the cause of the Veteran's bilateral hip disability.

As the examiner, however, did not address the Veteran's statements regarding his lack of mobility and activity as due to his lumbar spine disability, which could be an impact on calorie expenditure.

In September 2019, the Board found the VA opinions inadequate to decide the claims, remanded the claims to obtain a new examination and opinion providing a thorough rationale with consideration of the Veteran's contentions.

In June 2021, another VA examiner opined that it was less likely as not that the Veteran's bilateral hip DJD is less likely than not proximately due to his service-connected lumbar spine condition. Initially, the examiner stated, all medical knowledge indicates that the primary causative factors in development of DJD are increasing age, obesity and genetic factors. Notably, it was noted DJD can develop in several joints, and in persons predisposed to DJD, it is likely that this will occur rather than DJD isolating to a single joint or region (for example lumbar spine). However, the examiner explained that DJ in one particular joint or region is not known to drive development in a different joint or region and that the physiologic and pathologic processes involved in development of DJD do not lend a likely causative link.

With regard to the Veteran's lay statements that his obesity was related to his decreased mobility and inability to remain active, the examiner noted that clearly, the Veteran's weight gain was prior to his decreased mobility and symptoms of DJD as he reached a weight of 267 lbs. by March 1989 and 370 lbs. by September 2001 when he was still actively driving a CMV. It was further noted that despite the weight gain, he exhibited the ability to successfully operate the CMV, according to his companion of over 20 years who reported "[w]hen I first met him, he was driving a truck. And he could jump into the truck. He, could unload the truck. He could travel across country. And he was very active,." in about 1995 to 1997 when he had reached a weight of over 300 lbs.

Finally, the examiner opined that bilateral hip DJD is less likely than not aggravated by his gait change or stride deviation. In support of this opinion, the examiner reasoned that DJD is a progressive chronic disease which worsens over time and with increased or heavy use and observed that the Veteran's X-ray reports indicated that his DJD in his hips is mild to moderate. The examiner concluded, given the Veteran's age and employment history and body weight, a finding of mild to moderate DJD would be the least degree expected, and it would not be unexpected to find severe degenerative changes; his bilateral hip DJD has not progressed beyond its natural course, and is following a typical course of progression.

On the notion of direct-incurrence, the examiner opined that bilateral hip DJD is less likely than not incurred in or caused by his claimed in-service or events.

Concerning this, service treatment records show complaints of hip and lower extremity pain during an episode of lower back pain in February and March 1982 for which the Veteran was confined to quarters to precent worsening of his back condition. The Veteran reported that he was struck several times by a
and employment history and body weight, a finding of mild to moderate DJD would be the least degree expected, and it would not be unexpected to find severe degenerative changes; his bilateral hip DJD has not progressed beyond its natural course, and is following a typical course of progression.

On the notion of direct-incurrence, the examiner opined that bilateral hip DJD is less likely than not incurred in or caused by his claimed in-service or events.

Concerning this, service treatment records show complaints of hip and lower extremity pain during an episode of lower back pain in February and March 1982 for which the Veteran was confined to quarters to precent worsening of his back condition. The Veteran reported that he was struck several times by a "hose cart," sometimes in his hips, when the cart did not stop rolling and he was not paying attention. The examiner stated that he had personal experience with the type of hose carts the Veteran described and these incidents were likely of a very minor impact. The examiner further stated that the Veteran's sensation of hip and lower extremity pain during episodes of lower back pain are more likely due to radicular pain due to vertebral discs impinging upon his sciatic or femoral nerves, than an actual injury to his hip.

In support of the opinion, the examiner pointed out that the Veteran was able to perform the strenuous duties of a commercial vehicle operator for several years following his separation from service, which included very frequent heavy use of the hips for squatting, climbing, walking and other tasks. The examiner added that the Veteran had always been relatively heavy (lowest recorded weight of 230 pounds), which is likely to amplify the effect of strenuous force applied to his joints. In particular, it was noted that his body weight increased over time (to as much as 380 pounds) which was concurrent with his description of worsening symptoms of joint pain. The examiner explained that there is no medical literature or evidence to show that minor contusions or radicular symptoms are contributing factors to development of DJD; rather, there is much medical evidence to support a direct correlation between increasing body weight and development and worsening of arthritic pain.

Additionally, there is no medical evidence directly linking his bilateral hip disability to his service, nor is there otherwise any competent evidence linking his bilateral hip disability to his service-connected lumbar spine disability. Determining his bilateral hip DJD originated during his service or is secondary to service-connected disability does not fall within the realm of capabilities of a layman to offer probative opinion concerning. See 38 C.F.R. § 3.159(a)(1), (a)(2).

In sum, the probative evidence does not link this condition to the Veteran's service, either directly or secondarily by way of his service-connected DDD and IVDS of the lumbar spine. The evidence is against these claims, so service connection is denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990).

4. Entitlement to service connection for a right knee disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine.

5. Entitlement to service connection for a left knee disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine.

The Veteran has a diagnosis of right and left knee DJD, as noted in November 2011, December 2013 and June 2021 VA examination reports. Consequently, there is no disputing he has a current bilateral knee disability, but there also must be attribution of this condition to his military service either, as mentioned, directly, or secondarily by way of a service-connected disability.

However, it is not shown that the Veteran's bilateral knee DJD is related to any in-service injury, event or disease, or his service-connected lumbar spine disability caused or aggravates his bilateral knee DJD.

The November 2011 examiner opined that it was less likely as not that the Veteran's right and left knee disabilities were caused by the Veteran's service or his service-connected lumbar disc disease, finding that the condition was multifactorial in etiology, was likely related to his weight and genetic composition, and was likely unrelated to his
has a current bilateral knee disability, but there also must be attribution of this condition to his military service either, as mentioned, directly, or secondarily by way of a service-connected disability.

The November 2011 examiner opined that it was less likely as not that the Veteran's right and left knee disabilities were caused by the Veteran's service or his service-connected lumbar disc disease, finding that the condition was multifactorial in etiology, was likely related to his weight and genetic composition, and was likely unrelated to his back disease or the symptomatology noted in service.

The December 2013 examiner opined that it was less likely as not that the Veteran's right and left knee DJD was causally related to the Veteran's service, concurring with the November 2011 examiner that the Veteran's right and left knee disabilities are multifactorial in nature, including a genetic predisposition and the Veteran's body habitus. The examiner opined that the Veteran's weight gain is likely caused by lifestyle choices and genetic predisposition. The examiner addressed the Veteran's left knee chondromalacia, which was identified in service. The examiner, however, noted that chondromalacia of the patella does not cause multi-compartmental degenerative changes and, therefore, the Veteran's left knee DJD is less likely than not caused by or related to his in-service complaints. The examiner also found that the Veteran's right and left knee disabilities were less likely than not caused by his lumbar spine disability, altered gait, or altered body mechanics or due to the weight gain caused by his lumbar spine disc disease.

In March 2018 and April 2019, supplemental VA opinions were obtained regarding the etiology of the Veteran's bilateral knee disabilities. In the March 2018 opinion, the examiner contended that it was less likely as not that the Veteran's knee disabilities either manifested in service or were attributable to the Veteran's lumbar spine DDD, that it was likely age related with a genetic component. The examiner opined that, although the Veteran was diagnosed with left knee chondromalacia in service, his service treatment records did not show a left knee injury sufficient to predispose him to bilateral knee DJD. The examiner also noted that the Veteran complained of knee pain numerous times while in service, but that these were in the context of radicular pain from the Veteran's back; the examiner further noted that the Veteran's "knee symptoms looked to be transient or related to his back condition." The April 2019 opinion further specified that the Veteran's knee pain while in-service were complaints of radiculopathy and not a true knee joint problem. As to the causality of obesity in relation to the Veteran's service-connected lumbar spine disability, the March 2018 examination opined that obesity was multifactorial related to oral intake and calorie expenditure; therefore, the Veteran's lumbar spine degenerative disc disease was less likely as not the cause of the Veteran's obesity and, as such, this was less likely than not the cause of the Veteran's bilateral knee disability.

As the examiner, however, did not address the Veteran's statements regarding his lack of mobility and activity as due to his lumbar spine disability, which could be an impact on calorie expenditure.

In June 2021, another VA examiner opined that it was less likely as not that the Veteran's bilateral knee DJD is less likely than not proximately due to his service-connected lumbar spine condition. Initially, the examiner stated, all medical knowledge indicates that the primary causative factors in development of DJD are increasing age, obesity and genetic factors. Notably, it was noted DJD can develop in several joints, and in persons predisposed to DJD, it is likely that this will occur rather than DJD isolating to a single joint or region (for example lumbar spine). However, the examiner explained that DJD in one particular joint or region is not known to drive development in a different joint or region and that the physiologic and pathologic processes involved in development of DJD do not lend a likely causative link.

With regard to the Veteran's lay statements that his obesity was related to his decreased mobility and inability to remain active, the examiner noted that clearly, the Veteran's weight gain was prior to his decreased mobility and symptoms of DJD as he reached a weight of 267 pounds.
DJD can develop in several joints, and in persons predisposed to DJD, it is likely that this will occur rather than DJD isolating to a single joint or region (for example lumbar spine). However, the examiner explained that DJD in one particular joint or region is not known to drive development in a different joint or region and that the physiologic and pathologic processes involved in development of DJD do not lend a likely causative link.

With regard to the Veteran's lay statements that his obesity was related to his decreased mobility and inability to remain active, the examiner noted that clearly, the Veteran's weight gain was prior to his decreased mobility and symptoms of DJD as he reached a weight of 267 pounds. by March 1989 and 370 pounds. by September 2001 when he was still actively driving a CMV. It was further noted that despite the weight gain, he exhibited the ability to successfully operate the CMV, according to his companion of over 20 years who reported "[w]hen I first met him, he was driving a truck. And he could jump into the truck. He, could unload the truck. He could travel across country. And he was very active,." in about 1995 to 1997 when he had reached a weight of over 300 pounds.

Finally, the examiner opined that bilateral knee DJD is less likely than not aggravated by his gait change or stride deviation. In support of this opinion, the examiner reasoned that DJD is a progressive chronic disease which worsens over time and with increased or heavy use and observed that the Veteran's X-ray reports indicated that his DJD in his knees is mild to moderate. The examiner concluded, given the Veteran's age and employment history and body weight, a finding of mild to moderate degenerative joint disease would be the least degree expected, and it would not be unexpected to find severe degenerative changes; his bilateral knee DJD has not progressed beyond its natural course, and is following a typical course of progression.

On the notion of direct-incurrence, the examiner opined that bilateral knee DJD is less likely than not incurred in or caused by his claimed in-service or events.

Concerning this, service treatment records show a complaint of left knee pain in August and September1982 with a provisional diagnosis of chondromalacia for which the Veteran was treated with medications and physical therapy. The examiner stated that chondromalacia is often diagnosed in the setting of mild, otherwise unexplained anterior (patellar) knee pain and often resolves with conservative management and physical therapy. It was said to be not a recognized risk factor for development of DJD.

Regarding the Veteran's complaints of pain radiating to his knees, but the examiner stated that this was more consistent with radicular pain due to his lumbar spine issues of DDD and DJD and that these complaints appeared to have resolved after his back pain resolved in March 1982. The examiner noted that otherwise, the Veteran had no identifiable injury to his right knee during service.

In support of the opinion, the examiner pointed out that the Veteran was able to perform the strenuous duties of a commercial vehicle operator for several years following his separation from service, which included very frequent heavy use of the knees for squatting, climbing, walking and other tasks. The examiner added that the Veteran had always been relatively heavy (lowest recorded weight of 230 pounds), which is likely to amplify the effect of strenuous force applied to his joints. In particular, it was noted that his body weight increased over time (to as much as 380 pounds) which was concurrent with his description of worsening symptoms of knee and other joint pain. The examiner explained that it is not plausible that a single episode of chondromalacia which resolved within a month after proper treatment would result in DJD.

Additionally, there is no medical evidence directly linking his bilateral knee disability to his service, nor is there otherwise any competent evidence linking his bilateral knee disability to his service-connected lumbar spine disability. Determining his bilateral knee DJD originated during his service or is secondary to service-connected disability does not fall within the realm of capabilities of a layman to offer probative opinion concerning. See 38 C.F.R. § 3.159(a)(1
the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Consequently, the Board afford significant probative value to the VA examiners' medical opinions.

6. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine.

7. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected DDD and IVDS of the lumbar spine.

The Veteran has a diagnosis of right and left ankle joint DJD, as noted in November 2011, December 2013 and June 2021 VA examination reports. Consequently, there is no disputing he has a current bilateral ankle disability, but there also must be attribution of this condition to his military service either, as mentioned, directly or secondarily by way of a service-connected disability.

However, it is not shown that the Veteran's bilateral ankle DJD is related to any in-service injury, event or disease, or his service-connected lumbar spine disability caused or aggravates his bilateral ankle DJD.

The November 2011 examiner opined that it was less likely as not that the Veteran's right and left ankle disabilities were caused by the Veteran's service or his service-connected lumbar disc disease, finding that the condition was multifactorial in etiology, was likely related to his weight and genetic composition, and was likely unrelated to his back disease or the symptomatology noted in service.

The December 2013 examiner opined that it was less likely as not that the Veteran's right and left ankle DJD was causally related to the Veteran's service, concurring with the November 2011 examiner that the Veteran's right and left ankle disabilities are multifactorial in nature, including a genetic predisposition and the Veteran's body habitus. The examiner opined that the Veteran's weight gain is likely caused by lifestyle choices and genetic predisposition.

The examiner noted that there was no history of traumatic injury to his ankles to account for the current degenerative joint disease. The examiner noted that the Veteran had a history of an ankle sprain in service but went on to explain that isolated sprains do not causes DJD, and that, while chronic instability can, the Veteran did not present as having ankle instability upon examination. In making this assessment, however, the examiner did not address the finding of bilateral lax ankles, pes cavus, and crepitus on the left ankle with the anterior drawer test, as contained in April 1980 service treatment records.

The examiner also found that the Veteran's right and left ankle disabilities were less likely than not caused by his lumbar spine disability, altered gait, or altered body mechanics or due to the weight gain caused by his lumbar spine disc disease.

In March 2018 and April 2019, supplemental VA opinions were obtained regarding the etiology of the Veteran's bilateral ankle disabilities. In the March 2018 opinion, the examiner contended that it was less likely as not that the Veteran's ankle disabilities either manifested in service or were attributable to the Veteran's lumbar spine DDD. The examiner supported his opinion by asserting that while the Veteran had ankle pain related to the rigors of duty and an ankle sprain while in service, there was no specific injury that would have predisposed him to ankle arthritis and no arthritis was noted during the in-service x-ray. The examiner went on to state that neither of the prior examiners had found ankle instability on an objective exam. The examiner, however, did not address either the assessment of ankle laxity while in service, nor the finding that the left ankle ligaments were very lax and demonstrated some crepitus with an anterior drawer.

As to the causality of obesity in relation to the Veteran's service-connected lumbar spine disability,
's lumbar spine DDD. The examiner supported his opinion by asserting that while the Veteran had ankle pain related to the rigors of duty and an ankle sprain while in service, there was no specific injury that would have predisposed him to ankle arthritis and no arthritis was noted during the in-service x-ray. The examiner went on to state that neither of the prior examiners had found ankle instability on an objective exam. The examiner, however, did not address either the assessment of ankle laxity while in service, nor the finding that the left ankle ligaments were very lax and demonstrated some crepitus with an anterior drawer.

As to the causality of obesity in relation to the Veteran's service-connected lumbar spine disability, the March 2018 examination opined that obesity was multifactorial related to oral intake and calorie expenditure; therefore, the Veteran's lumbar spine DDD was less likely as not the cause of the Veteran's obesity and, as such, this was less likely than not the cause of the Veteran's bilateral ankle disability.

In the April 2019 examination, the examiner specifically opined as to the Veteran's reported incident of being hit with fuel carts in service; the examiner opined that it was likely painful, but that it should not cause ankle DJD. Moreover, he reasoned, there was no arthritis demonstrated on the left ankle on his x-ray in service. As such, he opined that it was less likely as not that the Veteran's bilateral ankle DJD was caused by injuries incurred by the hose cart while in service.

In September 2019, the Board found the VA opinions inadequate to decide the claims, remanded the claim to obtain a new examination and opinion providing a thorough rationale with consideration of the Veteran's contentions.

In June 2021, another VA examiner opined that it was less likely as not that the Veteran's bilateral ankle DJD is less likely than not proximately due to his service-connected lumbar spine condition. Initially, the examiner stated, all medical knowledge indicates that the primary causative factors in development of DJD are increasing age, obesity and genetic factors. Notably, it was noted DJD can develop in several joints, and in persons predisposed to DJD, it is likely that this will occur rather than DJD isolating to a single joint or region (for example lumbar spine). However, the examiner explained that DJ in one particular joint or region is not known to drive development in a different joint or region and that the physiologic and pathologic processes involved in development of DJD do not lend a likely causative link.

With regard to the Veteran's lay statements that his obesity was related to his decreased mobility and inability to remain active, the examiner noted that clearly, the Veteran's weight gain was prior to his decreased mobility and symptoms of DJD as he reached a weight of 267 pounds by March 1989 and 370 pounds by September 2001 when he was still actively driving a CMV. It was further noted that despite the weight gain, he exhibited the ability to successfully operate the CMV, according to his companion of over 20 years who reported "[w]hen I first met him, he was driving a truck. And he could jump into the truck. He, could unload the truck. He could travel across country. And he was very active,." in about 1995 to 1997 when he had reached a weight of over 300 pounds.

Finally, the examiner opined that bilateral ankle DJD is less likely than not aggravated by his gait change or stride deviation. In support of this opinion, the examiner reasoned that DJD is a progressive chronic disease which worsens over time and with increased or heavy use and observed that the Veteran's X-ray reports indicated that his DJD in his ankles is mild. The examiner concluded, given the Veteran's age and employment history and body weight, a finding of mild to moderate DJD would be the least degree expected, and it would not be unexpected to find severe degenerative changes; his bilateral ankle DJD has not progressed beyond its natural course, and is following a typical course of progression.

On the notion of direct-incurrence, the examiner opined that bilateral ankle DJD (osteoarthritis) is less likely than not incurred in or caused by his claimed in-service or events.

Concerning this, service treatment records show the Veteran had a mild left ankle sprain in March to April 1982. He was also diagnosed with unstable ankles and pes cavus in his ankles in April 1980. He was given a profile to allow him to wear "hilltop boots" to stabilize his ankles while on duty. The examiner noted, on physical examination, pes cavus or laxity of the ankle joints was not shown in June 2021.

natural course, and is following a typical course of progression.

On the notion of direct-incurrence, the examiner opined that bilateral ankle DJD (osteoarthritis) is less likely than not incurred in or caused by his claimed in-service or events.

The examiner stated that the in-service left ankle sprain was appropriately treated and apparently resolved, and ankle sprains are not typically a substantial risk factor for development of DJD. It was noted while DJD may develop more often in a joint with a history of recurrent or severe ankle sprains, there is much medical evidence to support a direct correlation between increasing body weight and development and worsening of arthritic pain and the greatest risk factors for development of DJD are age and obesity and genetic predisposition.

In support of the opinion, the examiner pointed out that the Veteran was able to perform the strenuous duties of a commercial vehicle operator for several years following his separation from service, which included very frequent heavy use of the ankles for squatting, climbing, walking and other tasks. The examiner added that the Veteran had always been relatively heavy (lowest recorded weight of 230 pounds), which is likely to amplify the effect of strenuous force applied to his joints. In particular, it was noted that his body weight increased over time (to as much as 380 pounds) which was concurrent with his description of worsening symptoms of joint pain. The examiner explained that it is not medically plausible that a single episode of mild ankle sprain/laxity of the ankle with pes cavus with no history of ankle injury would result in DJD. The examiner further noted that his history of heavy use after service with greatly increasing body weight would be substantially more likely to contribute to his DJD.

Additionally, there is no medical evidence directly linking his bilateral ankle disability to his service, nor is there otherwise any competent evidence linking his bilateral ankle disability to his service-connected lumbar spine disability. Determining his bilateral ankle DJD originated during his service or is secondary to service-connected disability does not fall within the realm of capabilities of a layman to offer probative opinion concerning. See 38 C.F.R. § 3.159(a)(1), (a)(2).

ANTHONY C. SCIRÉ, JR

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. J. In, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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